Provider Demographics
NPI:1609320134
Name:DAVIDSON, PAMELA
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:
Last Name:DAVIDSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:377 N ROLLING MEADOWS DR
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54937-9726
Mailing Address - Country:US
Mailing Address - Phone:920-921-9591
Mailing Address - Fax:920-921-0235
Practice Address - Street 1:377 N ROLLING MEADOWS DR
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54937-9726
Practice Address - Country:US
Practice Address - Phone:920-921-9591
Practice Address - Fax:920-921-0235
Is Sole Proprietor?:No
Enumeration Date:2016-08-12
Last Update Date:2016-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10273-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist